A nurse is collecting data from a newborn who was born 24 hrs ago. Which of the following images should the nurse identify as an indication that the newborn has erythema toxicum?
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The Correct Answer is B
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cantaloupe: Cantaloupe is considered high in potassium, with about 430 mg of potassium per cup. This makes it unsuitable for a client needing a low-potassium diet, as it can significantly contribute to elevated potassium levels.
B. Sweet potato: Sweet potatoes are very high in potassium, containing around 540 mg of potassium per half-cup serving. They are not recommended for individuals trying to manage or lower their potassium intake.
C. Orange juice: Orange juice provides approximately 500 mg of potassium per 1-cup serving. It is commonly avoided or limited in potassium-restricted diets due to its significant contribution to total potassium intake.
D. Wheat bread: Wheat bread contains a relatively low amount of potassium, about 60 to 70 mg per slice. Compared to the other options listed, wheat bread is much lower in potassium and is a better choice for clients who need to restrict potassium in their diet.
Correct Answer is B
Explanation
A. Temperature of 37.2° C (99.0° F): A temperature of 37.2° C is within the normal range and does not necessarily indicate infection. Mild temperature elevations are common in the immediate postoperative period due to inflammatory responses rather than infection, which typically presents with more significant fever.
B. Elevated WBC count: An elevated white blood cell (WBC) count is a classic and early indicator of infection. It reflects the body's immune response to a bacterial or viral invasion, and postoperative infections often present with leukocytosis, making it a key finding to monitor closely.
C. Pain rating of 4 on a scale of 0 to 10: Moderate pain is expected after surgery and does not, by itself, suggest infection. Postoperative pain should be assessed in context with other symptoms like redness, swelling, or drainage; pain alone, especially if stable, is not definitive for infection.
D. Increased urinary output: Increased urinary output is generally a positive sign of good kidney perfusion and hydration status. A decrease, not an increase, in urinary output would be more concerning postoperatively and could suggest complications, but not necessarily infection.
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